Surgical treatment of heart failure: heart transplantation and ventricular restoration surgery

Abstract

Heart transplantation (HT) is the only established surgical approach to the treatment of refractory heart failure. Survival after HT in Spain is 80% at 1 year, 70% at 5 years, and 60% at 10 years. The causes of death after HT depend on the time elapsed since transplant. In the first month, deaths are due mainly to acute allograft failure, between months 1 and 12 to infection and rejection, and thereafter to neoplasia, sudden cardiac arrest, or allograft vasculopathy. The main limitation on the application of HT to appropriately selected HF patients is the shortage of donors. Ventricular restoration surgery (VRS) comprises a set of surgical procedures for prevention of post-infarction ventricular remodelling. These techniques aim to reduce the volume and restoring the elliptical shape of the left ventricle by exclusion of the infarcted non-contracting segment. No randomized studies assessing the efficacy of VRS have yet been completed, and the results of the international multicentre trial STICH, in which patients with ischaemic cardiomyopathy are randomized to medical therapy, coronary bypass alone, or coronary bypass with VRS, are eagerly awaited. However, data from a large registry of patients with VRS show good results, with an overall 30-day mortality of 5.3% and a 5-year survival rate of 68%.